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Mental Health and Wellbeing after Military Service

An information booklet for veterans, other ex-service personnel, and their families.

© Commonwealth of Australia 2011

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the publications section Department of Veterans’ Affairs or emailed to [email protected].

National Library of Australia Cataloguing-in-publication data: Mental Health and Wellbeing after Military Service

ISBN 978–1–877007–69–9

Published by the Department of Veterans’ Affairs, Canberra 2011

Department of Veterans’ Affairs GPO Box 9998 Canberra ACT 2601

DVA publication P02203

Design and production: Me, Myself & I design

How to use this booklet

The transition back to civilian life after military service poses many challenges, not only for the ex-serving member but also for their family members and friends. It is a major change in lifestyle that is inherently stressful.

However, most people are resilient and successfully make the adjustment with the support and understanding of family and friends. Sometimes, a little extra help – information, self-help or professional support – is needed.

This booklet has been designed to provide information and advice for veterans, other former serving personnel, and their families, about mental health and wellbeing following military service. While the booklet contains information about mental health conditions that will help the reader to recognise any early signs of difficulty and know how to get help, it is also intended for those who are not experiencing mental health difficulties but want to generally improve their mental wellbeing.

Mental health and wellbeing is more than simply an absence of mental health conditions or disorders. A person with good mental health and a strong sense of wellbeing recognises their strengths and abilities, can cope well, is keen to make a contribution within their family and community, and will take part in enjoyable activities. To help you maximise your sense of wellbeing, a section is included in this booklet on practical coping strategies that anyone might benefit from if facing difficulties in their lives.

In the final section of this booklet links are provided to other self-help resources, treatment agencies and networks of support for those who recognise they need further help.

A large amount of information and advice is contained in these pages and we recommend that you do not try to digest it all in one go. Read a small bit at a time and, if necessary, re-read it several times until you understand it. Then move on to the next section. You will gain much more from this booklet if you read it slowly and carefully. You may wish to read it with your partner or a friend, and then sit down to discuss the contents.

We hope that the information in this booklet will help you understand the challenges and difficulties you or your family members may be experiencing. There is much that you can do to improve the way you think and feel, your relationships, and the way you function. Then you can have genuine ‘quality of life’ and good ‘mental health’.

Good luck!

Contents

1 The challenges of transitioning to civilian life

More than a change in career: The impact of transition on other aspects of your life 2

Military culture 3

Protective factors: What works? 4

Why is it important to take action to cope with the stress of transitioning? 6

Coping strategies 6

7 Mental health conditions

What is a mental health condition? 8

Why is it important to recognise mental health conditions? 8

Depression 8

What is depression? 8

Feelings of guilt 9

Protective factors 10

Anxiety 11

Posttraumatic Stress Disorder (PTSD) 12

What is PTSD? 12

Risk factors 12

Signs and symptoms 12

Managing symptoms 13

Occupational functioning 13

Traumatic grief 13

Sleep problems 14

Pain and other physical symptoms 14

Addictive behaviours 15

Alcohol and other drug use 16

Gambling 17

Internet use 17

Self-harm and suicide 18

Co-occurring mental health conditions 19

20 The impact on family

Coping within a family 23

Getting help 23

Domestic violence 23

25 Treatment options

The process of change 25

Your relationship with the therapist 26

The value of a thorough assessment 26

The continuum of help 27

Treatment delivery 27

Effective treatments 28

Treating depression 29

Treating anxiety 30

Generalised anxiety 30

Panic disorder and agoraphobia 30

Social anxiety 31

Treating PTSD 32

Trauma-focused ‘exposure therapy’ for PTSD 32

Cognitive Processing Therapy for PTSD 34

Relapse prevention and ongoing support for PTSD 34

Treating addictive behaviours 35

The role of medications 36

How long should I take medication for and what should I do if I don’t improve? 37

What can I ask my health practitioner about medication? 37

Alternative treatments 37

38 Coping and protective strategies

Diet 39

Being active 39

Sleeping better 41

Setting goals and solving problems 42

Helpful thinking 43

Building support 45

Keeping calm – Controlled breathing 46

Reviewing your progress 47

48 Helpful supports

VVCS – The Veterans and Veterans Families Counselling Service 49

Support groups 50

How to talk to your GP 51

The challenges of transitioning to civilian life

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There are many challenges to be faced when transitioning back to civilian life after serving in the forces. Few veterans or other ex-service personnel and their families would say that it is entirely ‘plain sailing’.

This is partly because major lifestyle changes are stressful for anyone. While many personnel leaving the military may initially experience some uncertainty and a loss of confidence, most make the adjustment successfully. At other times, the problems may not go away and for some, may become worse, unless they receive help.

For many, transition is not just about leaving a job but leaving a way of life that includes very high standards of personal conduct and commitment. The strong sense of purpose and belonging that is often part of serving in the Australian Defence Force (ADF) can be greatly missed when beginning a new chapter in life. When you transition, there is typically a sense of losing some part of yourself, or of no longer belonging.

These feelings may be stronger in those who left the services involuntarily and may be feeling some anger or shame as a result. Just as it took time to adapt to the military system, it also takes time to adapt after leaving.

More than a change in career: The impact of transition on other aspects of your lifeLeaving the ADF is more than a change in career; it can also impact on your lifestyle and home life. It is likely to change you as well. It may impact on the way you see yourself and the world, on how you feel and the way you do things. For example, you may think that it will be difficult to find a job you are qualified for in the civilian world, lose confidence in yourself and start avoiding applying for jobs. Alternatively, you may be looking forward to moving back home and feel more optimistic about life than you have been in a long time and start doing things you enjoy a lot more.

It is common for people leaving the ADF, and their families, to focus on only one aspect of transition and forget how much of their life can be affected. They can also focus on a difficult aspect of transition, like finding a new job, and forget that they are doing well with other major challenges in their life.

When you come into a new environment, you may be faced with many changes like losing friends, having to find a new job or a house. There are also less tangible things that you might have to adjust to. Your status at work may have changed; rules at work and in social circles might also be different. Your expectations about people and the way things are done may get challenged.

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As a result, some people who have left the ADF say that they have lost parts of themselves, lost their sense of direction, or feel like they don’t belong anywhere. Feeling ‘lost’ is a normal part of the adjustment process. It is not unusual for people to have these feelings for some time after they’ve transitioned

Military cultureFollowing are some aspects of military culture that might impact on the transition back to civilian life.

• Strong identification and bonding with military people, making it difficult for you to form new relationships and friendships in civilian life. You may feel you have less value in your civilian roles.

• Multiple deployments can lead to difficulties adjusting back to family life. Your partner may have had to learn to cope with all the day-to-day responsibilities such as paying bills, organising family routines and outings, attending parent–teacher interviews and kids’ sporting events. It can be difficult to renegotiate shared responsibilities. The tempo and priorities of family life may not sit well with you.

• A disciplined service environment may lead you to feel impatient and frustrated with civilian attitudes and behaviours that may appear to lack structure, direction and discipline. If you try to apply service standards (e.g., tidiness, timeliness, compliance with commands) to your partner, children and workmates, they are likely to feel it is unreasonable and may object. Your partner may often end up acting as a mediator between your children and you, which is a very stressful role.

• Experiences of hardship when on deployment may make life back in Australia seem indulgent. It may be very irritating when people seem to take the good things in life for granted or complain over, what seems to you, to be very little.

• During some periods of transition, you may have more free time than you want and a lack of structure or daily routine. This can quickly lead to frustration and low mood.

• Drawing parallels between skills acquired in the military and those required in civilian positions can be challenging. Marketable skills acquired in the military are much sought after by the civilian community (e.g., leadership, management, discipline, timeliness, neatness and the capacity to follow directives), but you need to recognise them as an asset.

Remember, that just as it took time for you and your family to adapt to military life and culture, it can take time to adapt to civilian lifestyle.

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Protective factors: What works?How you think and act will have an impact on your ability to adapt to new circumstances. There is now a great deal of knowledge about beliefs and habits which help people successfully adapt to change.

How do people who successfully adapt to change think?

• They think about what they have control over, even if it is a small thing; they don’t try to influence things they can’t control.

• Instead of telling themselves that they ‘should’ do something, they think about what gives meaning or value to what they need to do.

• They try to see where opportunities lie in the future and don’t spend a lot of time worrying and thinking about how things can go wrong.

• When faced with a problem they spend more time thinking about solutions and less time thinking about negative consequences of the problem.

What do people who successfully adapt to change do?

• They don’t try to do everything on their own; they ask for support and involve other people.

• They focus on the problem at hand, break it down into manageable chunks and set goals to resolve it.

• They try a different approach if their first solution doesn’t work.

• They don’t tend to use avoidance to cope (e.g., procrastinating), ignore what is happening, or act as though life will remain the same.

• They balance getting things done with looking after themselves and taking time to relax and enjoy time with their families.

• They engage in regular physical activity.

• They try not to take on too much, but also plan some activities and bring structure to most days.

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Optional exercise: Protective factors for change

When we are struggling with major change in our life, it can be helpful to think back to a time when you successfully adapted to change and to draw on the lessons learnt at that time. So, what are the resources and strategies you have used in the past to adapt to change in your life?

Think of one time in your life where you had to deal with a major change:

Which strategies did you use in order to adapt to your new circumstances?

What help and resources did you receive?

Which of the above strategies and resources might be useful to your life now?


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Why is it important to take action to cope with the stress of transitioning?It is very important to tackle any issue as early as you can before it becomes entrenched as a severe problem in the long term. The consequence of not tackling frustration, intense anger and aggression, anxiety, low mood and stress, is that major anxiety and depressive conditions, and excessive alcohol and other drug use (including prescription drugs), can develop. When this happens, relationships struggle to survive without a lot of support and help. Long-term stress also compromises our immune system and is associated with the development of many different physical diseases.

Coping strategiesIf you recognise that you or your family members are struggling with some of the challenges of transition, then it is likely that some of the coping strategies found in this booklet will be helpful for you.

You might also benefit from further support or professional help (see the Helpful supports section at the end of this booklet).

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Mental health conditions


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What is a mental health condition? A mental health condition occurs when a set of distressing symptoms (thoughts, feelings and behaviours) has a severe impact on our psychological, social (including relationships) and vocational functioning. This is not to say that it is always easy to recognise or diagnose a mental health condition, as the nature and severity of symptoms can vary from one person to the next. Our personal characteristics and the environment in which we are living influence how we will experience a mental health condition. For example, high-stress environments can trigger symptoms.

Why is it important to recognise mental health conditions? If mental health conditions are not recognised and treated, they usually become worse over time, and can cause major problems and disability in other areas of our life. The good news is that most commonly occurring mental health conditions can be successfully treated by psychological treatments. Sometimes medications will also help when used along with psychological treatments.

The earlier a condition is treated the more quickly it will respond to therapy. The support of our families and friends is important, and our living situation needs to be stable and relatively low stress to get the best outcomes.

DepressionDepression is a commonly occurring mental health condition. Over the course of our lifetimes, about one in four or five Australians will experience a major episode of clinical depression. However, just because it is common does not mean it is insignificant in any way; it is a very distressing and disabling condition if left untreated, and the risk of suicide is many times greater in depressed people.

Before describing depression, it is important to say what it is not. Depression is not simply feeling low from time to time, as we all do. However, feeling low is part of depression, so the distinction can be a confusing one. If you feel low continuously for two weeks, you may have become depressed. Many men (and some women) find it hard to admit, even to themselves let alone others, that they are depressed. Indeed, we may continue to function quite well (especially at work), hiding or masking our depression, from others. Unfortunately this ‘head-in-the-sand’ approach to any mental health condition will not make the problem go away and may make it worse in the long run.

What is depression?Depression is a persistent state of low mood and a loss of interest or pleasure in activities that were previously enjoyable. Life becomes flat and grey, and nothing seems fun, exciting, or enjoyable anymore. In more severe cases, the person may believe that life is no longer worth living.

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Common symptoms of depression are:

• feeling low, down in the dumps, miserable

• feelings of worthlessness, helplessness, and hopelessness

• lack of energy, easily tired

• lack of enthusiasm, difficulties with motivation

• loss of interest and pleasure in normal activities

• lack of appetite and weight loss

• loss of sexual interest

• difficulty sleeping, or sleeping too much

• poor concentration, memory, and decision making

• thoughts of suicide/death.

Prolonged stress and anxiety, and medical conditions (especially constant pain) are risk factors for depression; it is important that these issues are also addressed.

Feelings of guiltDepression is often associated with guilt. If you are an ex-serving member who has experienced war, you may feel guilty that you survived while others did not; it may be about what you had to do to survive; it may be related to things you did in combat about which you now feel ashamed. The nature of military operations can be such that there may be no acceptable or ‘good’ options in some situations. Sometimes the guilt results from trying to apply civilian, or peacetime, standards to a combat situation. If you judge your actions back then by peacetime community standards you may feel guilty. For some veterans, these feelings can be very damaging and can get in the way of recovery. They are hard to work on, but it is important to try and reduce the intensity and strength of guilt by challenging the thoughts and beliefs associated with those feelings.

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Depression might also result if your view of the world as a fair place has been shattered and you feel that your values were violated by your experience of war or serving in the military. It may take time, and the sharing of your experiences and thoughts with supportive and understanding people, to come to terms with these experiences and restore your core values and beliefs.

Protective factorsIf you are ‘socially connected’, you are less likely to develop severe depression. Indeed, social isolation is a major risk factor. What does it mean to be ‘socially connected’? It means that you will regularly attend family and community activities/events and play a role in organisations (of whatever type); that is, you will have a sense of community ties, of being needed, and of making a contribution to the wellbeing of others.

The close support of at least one family member or friend is also a protective factor for depression. The stronger and more cohesive your family ties are, the less likely it is that you will become severely depressed, or at least if you are depressed you will recover well with help. Being able to share your thoughts and feelings with people you trust is important.

Facing up to and attempting to solve problems (rather than trying to avoid them) also helps prevent severe depression. Developing your social and coping skills will help you to overcome challenges. Learning the habit of realistic and helpful thinking will ‘inoculate’ you from depression (constant negative thinking is a big risk factor for depression).

These protective factors are part of the coping strategies that you can begin to use.

“ It is vital if you are experiencing depression that you seek support and help (see the ‘Helpful supports’ section at the end of this booklet). This is especially so if you are having frequent thoughts of suicide and have thought about how you might achieve it. ” Most people will respond quite quickly to professional therapy for depression, sometimes in conjunction with anti-depressant medication.

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AnxietyAnxiety is best described as a state of apprehension and worry that something unpleasant is about to happen. Some anxiety from time to time in our lives is absolutely normal. In fact, it has a protective value in alerting us to potential threat and putting us in a state of readiness. An adrenaline boost occurs with a surge of anxiety, making us instantly ready to respond to danger by ‘fight or flight’. People who experience very little anxiety tend to also take extreme, and possibly unwarranted, risks that most of us would choose to avoid if we could.

So, when does anxiety become problematic? Anxiety requires treatment when it is a frequent and dominant feature in your life. Anxiety can also be a problem if it comes in very intense bursts (panic attacks) in response to specific situations such as crowded places or public transport. Social anxiety (a fear of embarrassment or performance-related anxiety) can result in a very narrow life without much enjoyment if social events are avoided. Anxiety can lead to social withdrawal and being house-bound (agoraphobia) in order to avoid a wide array of threatening situations, which is also a major risk factor for developing depression. Anxiety responds well to treatment that focuses on thought processes and managing stress responses. If left untreated, chronic anxiety and stress is associated with a wide range of physical illnesses.

Anxiety (especially when experiencing a panic attack) can be very unpleasant and sometimes frightening. You may believe that you are going to die from a heart attack or go crazy. The symptoms include:

• apprehension, fearfulness, or terror

• shortness of breath and tightness in the chest

• palpitations and increased heart-rate

• sweating

• shaking, trembling, or dizziness

• fear of losing control or going crazy (and fear of the embarrassment this would cause)

• excessive worry

• feeling restless and on edge

• muscle tension

• physical disorders (e.g., skin complaints, stomach upsets, aches and pains).

It is easy to see how the experience of being under constant threat in a military operation could lead to the ‘anxiety switch’ becoming stuck in the on-position.

Anxiety often readily responds to treatment. The use of calming techniques such as controlled breathing and planning for stressful situations can be a great help (see the ‘Coping strategies’ section).


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Posttraumatic Stress Disorder (PTSD)What is PTSD?PTSD is a psychological response to the experience of intense traumatic events, particularly those that threaten life. You may have experienced a threatening event that has caused you to respond with intense fear, helplessness, or horror. For military veterans, the trauma may relate to direct combat duties, being in a dangerous war zone, or taking part in peacekeeping missions under difficult and stressful conditions. For civilians, the trauma can stem from either man-made events (such as physical assault, sexual assault, accidents, and witnessing the death or injury of others) or natural disasters (such as fires, earthquakes, floods and cyclones).

It is normal to experience distress when confronted with trauma, and most people recover over the first week or two, particularly with the help of caring family members and friends. However, for some people the symptoms do not seem to resolve quickly. It is also common for symptoms to vary in intensity over time. Some people go for long periods without any significant problems, only to relapse when they have to deal with other major life stresses. In rare cases, the symptoms may not appear for months, or even years, after the trauma. The reasons for this are not fully understood, but a common observation is of a veteran who, when busily immersed in a successful career and family life appears to cope quite well, only to begin to exhibit symptoms when they retire from work.

Risk factorsPTSD is not an inevitable consequence of experiencing what, on the face of it, seems to be a traumatic event, such as death at close quarters in war. It is not fully understood yet as to why one person exposed to a similar, or even the same event, might go on to develop PTSD while another person does not. Some risk factors have been identified: being exposed to trauma earlier in life, multiple exposure to traumatic events, an absence of social support after a trauma, and the presence of other major life stressors.

Signs and symptoms If you have PTSD, you may often experience feelings of panic or extreme fear, resembling what was felt during the traumatic event. In PTSD there are three main types of difficulties:

Re-living the traumatic event – through unwanted and recurring memories and vivid nightmares. It can feel as though the events were happening again; this is referred to as ‘flashbacks’, or ‘reliving’ the event. There may be intense emotional or physical reactions, such as sweating, heart palpitations or panic, when reminded of the event.

Being overly alert or wound up – seeing danger everywhere and being ‘tuned in’ to threat. As a consequence, you may become jumpy, on edge, and feel constantly on guard. This can lead to being overly alert or watchful and to having problems concentrating, sleeping difficulties, irritability, and becoming easily startled, particularly by noises that remind you of the traumatic event.

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Avoiding reminders of the event and feeling emotionally numb – deliberately avoiding activities, places, people, thoughts or feelings associated with the traumatic event. You may also lose interest in day-to-day activities, feel cut off and detached from friends and family, or feel flat and numb. This can lead to social isolation, a major risk factor for depression.

A health practitioner may diagnose PTSD when a number of symptoms in each of these three areas occur for a month or more, and when the symptoms lead to significant distress or impact on the ability to work and study, and on the quality of relationships and day-to-day life.

Intense anger is often associated with PTSD. Many veterans feel let down, abandoned, and judged by others. The power of their anger may be frightening for them and they may often feel considerable remorse afterwards. Such symptoms frequently cause major problems at work, as well as with family and friends.

Managing symptomsSome benefit can be obtained by managing the symptoms of PTSD through the kind of ‘Coping strategies’ included in this booklet. However, managing symptoms is not a substitute for trauma-focused treatment of PTSD, in which the traumatic memories are confronted and dealt with so that you are no longer constantly at risk of severe symptoms emerging in daily life (see the ‘Treatment’ section for more detail).

Occupational functioningIf you have PTSD, you may have difficulty coping with pressure at work. Irritability, jumpiness, mood swings, poor concentration, and memory problems may lead to disputes in the workplace and frequent job changes. You may be intolerant of other people’s inefficiency, comparing ‘civvystreet’ with the organised, military way. Some veterans with PTSD adopt a workaholic pattern, shutting themselves away in their work and putting in very long hours. This seems to be part of the avoidance component of PTSD; keeping very busy helps to prevent the memories and unpleasant thoughts coming back. Other veterans find that their problems prohibit them from working effectively at all. The decision to stop work is a difficult one. You may need to weigh up the personal cost of remaining in the workforce against the benefits of trying to continue work (e.g., sense of belonging, achievement, self esteem, and financial wellbeing). Reducing hours, or taking less responsibility, is a workable compromise for some people with PTSD.

Traumatic griefAfter the loss of a friend in battle or an accident, the grief associated with trauma may be unresolved over many years and lead to social withdrawal. If you have traumatic grief you may be unwilling to get emotionally close to someone again. You may have feelings of anger because the death was ‘unfair’, or feelings of powerlessness or guilt about the circumstances of the death. Sometimes people hold onto, and prolong, their grief because they feel it will be a betrayal of the lost one to move on.


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Traumatic, or ‘complicated grief’, is sometimes confused with PTSD or depression, and, of course, can occur along with those conditions. Indeed, untreated and unresolved traumatic grief can develop into major depression. However, traumatic grief needs to be treated separately to other conditions. An opportunity to directly focus on the feelings and thoughts associated with the loss will be necessary in order to resolve traumatic grief. Some professional help may be required to take a structured approach to reframing thoughts about the loss, and to explore related feelings. It is possible to adapt and move on without ever losing a sense of sadness at the loss, and it is normal for waves of grief to peak from time to time, especially at anniversaries.

Sleep problemsDisturbed sleep is common for a variety of reasons and can be harmful to your wellbeing. Sometimes it is just a consequence of poor sleep habits (e.g., too much alcohol or caffeine before sleep, too much physical or mental stimulation before going to bed). Sleep problems can develop as a consequence of disrupted sleep patterns in operational zones (somewhat like the disrupted sleep patterns of shift workers or parents getting up to settle young children).

However, sleep problems can also be a sign of poor mental health. Depression can result in too much or too little sleep. Anxious thoughts replaying over and over can keep people awake. Frequent nightmares will disrupt sleep patterns.

Poor sleep habits can respond to a few simple strategies as found in the ‘Coping strategies’ section. Sleep problems associated with mental health conditions often respond well to professional help.

Pain and other physical symptomsChronic stress is associated with a wide range of physical symptoms such as skin complaints and general aches and pains. Pain related to injuries sustained while serving can greatly undermine your sense of wellbeing (e.g., chronic back pain is associated with general disability, emotional distress and depression).

When a mental health condition occurs along with chronic pain, the pain may be felt more intensely and be more distressing. Untreated pain impacts very negatively on occupational, social and recreational functioning. Not surprisingly, this can induce a sense of hopelessness and worthlessness and lead to social isolation and severe depression. It is common for people to self-medicate with alcohol or other drugs when struggling with chronic pain. The presence of chronic pain carries an increased risk of suicide in veterans.

Physical problems and mental health conditions are risk factors for each other, e.g., heart disease can lead to depression and anxiety, and depression and anxiety (if left untreated) can lead to heart problems. People with diabetes are twice as likely to develop depression. When a person has both an untreated mental health condition and physical problems, health and social outcomes are very poor.

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It really is important to get effective treatment for your physical complaints if you are to minimise your risk of developing, or making worse, any mental health conditions. Treatment of your mental health issues will improve your physical status (e.g., treatment for depression reduces the blood sugar levels of diabetics). Your mind and body really are one united system that cannot be neatly divided for the purposes of physical and psychological treatments.

It is vital that a person suffering from chronic pain receives pain management treatment, along with treatment for mental health conditions such as depression, PTSD and other anxiety states.

Addictive behaviours When a behaviour or activity is very pleasurable (at least initially), and when it also helps to relieve your anxiety, there is the potential to become over-involved in the behaviour. This process is sometimes referred to as ‘self-medicating’ low mood, anxiety and life problems. When you begin to rely on an activity to make you feel better, and when you are struggling to control your involvement even when it is evident to you that it is harmful, the process can be referred to as an ‘addiction’. The best way to avoid developing an addiction is to restrict your involvement in potentially problematic behaviours. Frequent and regular (especially daily) engagement in a behaviour greatly increases the risk of that behaviour getting out-of-hand. Addictions can take many forms; some of the most common ones that veterans and other ex-service personnel and their families experience are covered in the following pages.


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Alcohol and other drug useIn an attempt to cope with unpleasant symptoms of mental health conditions, we may turn to alcohol or other drugs. Many veterans with chronic PTSD also have major problems with alcohol and other drugs. In Australia, the most common drug problem, leaving aside tobacco, (which is the biggest killer in the long run) is alcohol, but many people also use other drugs (e.g., cannabis or prescription medications) to excess. Excessive alcohol and drug use impairs your ability to function effectively and to relate to other people. It can cause great difficulties in areas such as physical health (liver and brain damage, and increased risk of many types of cancer), relationships, work, and finances. Alcohol binges are associated with explosive anger and violence and impulsive decisions to suicide.

Excessive alcohol use can also cause depression and make anxiety much worse. If you are dependent on alcohol (that is, your nervous system now requires alcohol on a daily basis to just feel ‘normal’ and to avoid withdrawal symptoms), a month of abstaining from alcohol could result in depression and anxiety greatly reducing. Of course, some people will need treatment for anxiety and/or depression despite abstinence from alcohol.

Cannabis use is often thought by many users to be a lower risk option than alcohol. While this is true in the sense that fewer social problems seem to be associated with cannabis than for alcohol, heavy cannabis use negatively affects concentration, attention and memory. Brain damage can also result from

regular and heavy use of cannabis (especially in the still-developing brains of adolescents and young adults), eventually impairing the user’s ability to plan, coordinate and communicate well. Heavy use of cannabis robs users of motivation to get out and do things, which is then a risk factor for depression.

Amphetamine (‘speed’) or meth-amphetamine (‘meth’ or ‘ice’) use often starts as a party drug, but if use escalates and becomes frequent and dependent, then unpredictable, impulsive, aggressive and paranoid behaviour can occur.

It is common for people with mental health conditions to be very heavy tobacco smokers. Nicotine in tobacco is a very seductive drug as it has the unique properties of being both calming and improving alertness – a powerful addiction combination. The great risk is that over time, the person’s health will severely deteriorate (with a high risk of emphysema or incurable cancer), adding further to their psychological distress.

There is a lot of information and help readily available for alcohol and other drug use (see the ‘Helpful supports’ section at the rear of this booklet).

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GamblingAustralians gamble more per head of population than any other nation. That’s not necessarily a problem in itself, as gambling can be recreational and enjoyable. The same principle applies with alcohol; it’s about keeping the balance right, fitting gambling around a healthy lifestyle.

Problems arise when losses exceed what can be afforded and when the over-riding motive is to win money or to escape from boredom and depression. It is then very easy for things to go horribly wrong with massive repercussions for bank balances and debt. Fraud is common when problem gamblers desperately ‘chase’ their losses to try and repair the damage.

Families are ripped apart; it is very difficult to regain the trust of family members and friends when it is discovered that many assets have gone or bankruptcy is being faced. Problem gamblers often become depressed and anxious as a result of their gambling and have high rates of suicide.

In recent years, many more Australians have developed a problem with gambling because of the availability and characteristics of poker machines. Poker machines regularly pay out small wins and this pattern can be enough to get some people hooked, even though they are quickly amassing large losses. Some veterans with mental health issues develop a problem with gambling. These veterans say they are gambling to escape problems in other areas of their lives.

There is some concern that the next big wave of problem gambling will occur in relation to sports betting over the Internet. The bets can be placed at home, many types of bets can be laid, and new odds are provided as a game unfolds.

There is also a link between alcohol and gambling. Consuming alcohol while gambling can cloud judgment, leading to larger bets. Some people have found that after successfully bringing their drinking under control, they have begun to gamble excessively.

Effective treatments exist for problem gambling once the person recognises he or she has a problem and wants to do something about it. Most people with a gambling problem eventually bring it under control. Help services for gambling can be found through your GP, your local health or community centre, state government websites or on the DVA alcohol website at www.therightmix.gov.au.

Internet use Excessive use of the Internet (sometimes called ‘cyber-addiction’ or ‘Internet Addiction Disorder’) can be very damaging to our relationships. Regardless of the preferred activity engaged in over the Internet, the issue is whether it is consuming most of the your time and energy to the detriment of other aspects of your life.


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It is debatable as to whether this behaviour really constitutes a mental health condition or is just a reflection of the growing influence of technology on our lives. Regardless, many counsellors who work with veterans and other ex-service personnel are indicating, anecdotally, that it is an issue that is commonly presenting in clients and is having a severe impact on relationships and family functioning.

Self-harm and suicideThe risk of self-harm, either intentionally or by accident, is much higher if you have a mental health condition. Accidents are more likely when risks are being taken, such as drink-driving or handling machinery when intoxicated. A fatalistic attitude (‘what will be, will be’) about life may result from war experiences, if you feel you had little control over outcomes, and when feeling hopeless and helpless about your future. This approach to risk-taking also puts other people at risk.

One of the myths about suicide is that you have to be severely depressed to attempt suicide. While being severely depressed certainly increases the risk of suicide many-fold, the vast majority of depressed people never attempt suicide, while many of those who do attempt suicide are not clinically depressed at the time. Suicide may follow domestic disputes, separation from partners and families, intense anger at a sense of injustice, work problems, debt, legal problems, chronic illness and other major life problems, with or without depression.

It is not possible to accurately predict who will attempt suicide, except that past suicide attempts increases the risk for future attempts. Some people with many risk factors will not attempt suicide while other people, who seemed to have few risk-factors, may shock others with their attempted, or completed, suicide. Some of the major risk factors for suicide in veterans and other ex-service personnel are:

• social isolation

• unresolved interpersonal conflict

• severe physical conditions, including chronic pain

• mental health conditions, especially depression, bi-polar (manic-depression) disorder, PTSD and other anxiety conditions

• alcohol or other drug use problems

• access to firearms or other lethal means.

These risk factors are significant for both male and female veterans and other ex-service personnel. If you have these risk factors, it is strongly recommended that you seek professional help. If someone you care about seems to be at risk, but they do not wish to seek professional help, it may still help if they receive social support and an opportunity to discuss how they are thinking and feeling.

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Peers and family members of people who seem to be at risk might wish to consider attending a ‘suicide alert’ course where you can learn how to discuss suicide with someone you think is at risk and encourage him or her to seek help (see the ‘Support section’ at the end of this booklet for more detail). You may also wish to seek some support for yourself from a counsellor.

Co-occurring mental health conditionsIf you have more than one mental health condition at the same time (sometimes referred to as ‘comorbidity’), your overall functioning is likely to be more impaired with poorer quality of life. Problems will be interwoven in a complex manner. About one-third of veterans and other ex-service personnel who have been diagnosed with a mental health condition will have two or more conditions (the real rate may be higher if alcohol and other drug problems are being under-reported). Of those who have been diagnosed with PTSD, a majority will also have another anxiety condition, depression or a substance use problem.

When this is the case, professional treatment is highly recommended, as a skilled therapist will need to conduct a comprehensive treatment and decide whether issues and conditions should be treated together or one at a time.

Many other mental health conditions will improve when PTSD is successfully treated, but some may require additional treatment on their own. For example, if you have depression, PTSD will usually be treated first because depression often improves as the symptoms of PTSD become less pronounced. But if you are feeling flat, hopeless and unmotivated, this may prevent you from working through trauma memories and, consequently, you may need treatment for the depression first.

If you have been using drugs and/or alcohol to help you cope, treatment will include strategies to help you reduce your consumption to safe levels, or to stop entirely. If you are only focusing on managing PTSD, and drug and alcohol problems are left untreated, you are unlikely to get better in the long term.

The impact on family

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Families are complex systems. When one member is not travelling well it will, inevitably, impact on the wellbeing of other members of the family. However, the flip side is that family members can easily be a strong and positive influence on the relative with a mental health condition. As well the partner or other family member will also need to look after him or herself and get their own needs met.

Not all families of veterans, and other ex-service personnel who have experienced war combat, function poorly. Most cope well with the support of good community connections, strong relationships within their extended family, and with a balanced family life that includes many enjoyable activities.

However, even when a veteran has a supportive and caring family the veteran can still be isolated, especially if they feel their distress will be too much for their family members to bear, and consequently try to keep his or her distress to themselves. When this sort of isolation is a problem, getting help from a professional can be very important in helping to link the veteran to supports and in opening up communication within the family.

Mental health conditions can directly affect family life when there is difficulty in expressing feelings and emotions (e.g., love and enthusiasm for relationships). This may lead partners, family members, and friends to feel ‘pushed away’ and rejected. This, in turn, can result in the veteran feeling isolated and unloved.

Feelings of worthlessness, anxiety, and depression may also result in difficulties in sexual intimacy. This tends to compound feelings of inadequacy or guilt and the relationship may suffer badly as a consequence. Sexual intimacy can also be affected by the side effects of medication for mental health and physical health conditions. Discuss any concerns about the sexual side effects of medication with your doctor. He or she might be able to suggest changes to the type, dosage or timing of your medication to minimise these issues.

If you have a mental health problem you may feel ‘cut-off’ from other people. This often leads to reduced participation in activities and hobbies that were once enjoyed. This absence of shared and enjoyable activities makes it difficult to have a normal family life. The partner is often left with the full burden of running the family. In some cases, a great deal of time is spent focusing on the veteran’s problems at the expense of the partner’s needs.

Partners of veterans and other ex-serving personnel have higher rates of depression, anxiety disorders, sleep disorders, acute stress reactions and long-term difficulty in coping with major stressful change than partners of non-veterans.


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Children can easily become the focus of irritation and anger when a parent is not coping well. The partner may make attempts to control the children’s behaviour when the veteran parent is home, in order to avoid conflict. This is obviously a very stressful, and unsustainable, approach which fuels resentment in family members. The children in this situation, along with the parent-partner, typically talk about ‘walking on egg shells’, anxious not to do or say something that will upset the parent with a mental health condition. If this situation persists for many years, and the child’s anxieties are not addressed, difficulties can persist through into adulthood for these children. If your child is showing signs of high anxiety or depression, with marked changes in behaviour, talk to your GP regarding a professional assessment.

Single–parent families are especially vulnerable to stress, with children from single parent families more likely to develop mental health issues of their own. Their need for support from extended family, friends and community groups should be recognised. This is especially so in the aftermath of parental separation, with its many inherent stresses and tensions, and professional help should be considered. However, children can do well after break-ups if they feel their interests are the priority of both parents. The parent who leaves the family home at the time of separation is also often in need of much support at this time.

Single veterans and other ex-serving members may be prone to social isolation and mental health conditions. Extended family and community supports are critical for the wellbeing of single veterans who may neglect to look after themselves. Concern, support and prompts from others to get physical check-ups, or to seek help for mental health issues, may be necessary.

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Coping within a familyPartners and close friends are often at a loss as to how to help someone with a mental health condition. There are several things that loved ones can do to help. If possible, listen and empathise when the person wants to talk. Remember that it may be very hard for them to express what they’re going through. A sympathetic listener is important in minimising the tendency of people with mental health problems to withdraw and ‘shut down’. It is best not to say, ‘I understand what you’re feeling’ (you probably don’t, unless you have had similar experiences). Instead, show your empathy by comments such as, ‘It must be really difficult for you’; ‘I can see that it upsets you’; ‘Is there anything I can do to help?’

Spend time with your friend or loved one. There is no substitute for personal presence. Just keep doing the usual things that people do together. Do not feel that you have to be their counsellor. Don’t be afraid to suggest that they see a psychologist, psychiatrist, or counsellor, or that they seek support from peer groups. But remember to do this in a tactful and caring manner, not in the middle of an argument!

Getting helpIf as a veteran, partner or child of a veteran you are aware your relationships and family life are struggling, please consider seeking professional help (see the ‘Support section’ at the end of this booklet). If things are going pretty well, but you need some fine-tuning in your life, then consider using the relevant parts of the ‘Coping strategies’ section. Supporting someone with a mental health condition can take a toll on you, sometimes so much so that your own health can be affected and you can no longer help him or her effectively. It is crucial that you take some time to reach out to friends and other supportive people in your community. You can also enlist the help of a counsellor or a support group. Your GP or a mental health practitioner can provide you with information and the names of people and organisations that can help.

There are also telephone ‘hotlines’ with counsellors trained in the needs of raising children in highly stressed families (you may like to check out the Raising Children Network on the Australian Parenting Website http://raisingchildren.net.au/ for contact details of where to get help).

Domestic violenceWhile there is certainly a link between anger and untreated PTSD, this does not provide an explanation or excuse for violence within the home. PTSD cannot be used as an excuse for hurting others. Violence within the family needs to be directly addressed through domestic violence services and other professional help. Your GP or your local health or community centre will have details of services in your area.

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Treatment options

Treatment options

The intention of this section is to provide an overview of the principles of effective treatment, rather than a detailed account of treatments for all conditions (which would go beyond the scope of this booklet). The exception is that detail is provided on treatment for PTSD, as it is a very specific treatment.

You will be a more informed ‘consumer’ of psychological treatments after reading this section, but you will still require more detailed explanations of specific treatments from therapists should you be seeking professional help.

The process of changeMajor change in our functioning (the way we think, feel and behave) seldom occurs ‘overnight’. Rather, it is a process; the first step is to become aware of the need for change. This awareness will develop when we are feeling uncomfortable about the way things are for us. We then begin to contemplate the advantages of change over staying stuck. Sometimes some material or resources (like this booklet) may help people to become contemplators of change. Relatives and friends might have a gentle role to play in making you aware of the need for change through having an open discussion with you about the advantages of change. However, we all know that if others (especially loved ones) push too hard, we tend to retreat into our shells and resist change.

After deciding that change is necessary, we can prepare ourselves for taking action. This is probably what you are doing if you have got this far in this booklet. It involves asking questions about what is involved in treatment and what commitment is required of you and your family to make this happen. Treatment outcomes are much better when a person is fully informed and motivated.

The next stage is to take the plunge (most people find it scary to seek help), take action by arranging treatment (some leads for finding qualified people can be found in the ‘Helpful supports’ section at the end of this booklet), and be prepared to follow through on the process. Progress may be slower than you had hoped for, and sometimes more challenging than you feel comfortable with, but with the support of a skilled and caring therapist using evidence-based treatments, the vast majority of people will begin to improve. Sometimes people pull out of treatment before it is complete, and although this is less than ideal, it does not mean there has been no benefit. Upon returning to treatment at a later time, it is often possible to quickly pick up the threads.

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In the process of change, after making good progress and feeling a lot better, it is normal to have periods where you feel you have slipped back, or lapsed into old ways of thinking, feeling and behaving. Seldom is change ‘full steam ahead’, but rather more like ‘two-steps forward and one-back’, at least for a while. This is why most treatments have a part called ‘relapse prevention’ to help anticipate and deal with difficulties that will lie ahead. But eventually, with perseverance and support, and maybe an occasional tune-up treatment session, change will be consolidated and you will consistently feel a lot better and cope well.

Your relationship with the therapistA good relationship with your therapist, in which you feel understood and supported, and certainly not judged in anyway, is very important to how much you will benefit from treatment. You need to have confidence in your therapist, to trust that they know what they are doing. Trust may need a few sessions to fully develop. If, however, at any stage you feel the match with your therapist is not a good one, you have the right to consider changing therapists. It may be helpful that you express your concerns to the therapist first, as an open and honest discussion might bring things right!

It is best that you feel informed and understand what is happening in therapy at every stage. Ask for clarification if necessary. You will benefit most when you understand the process of therapy and when you are an active participant. After all, a good outcome from therapy is that eventually you will have become your own ‘therapist’, able to apply the strategies of treatment as you go about your life.

The value of a thorough assessmentSometimes you may get a little impatient at the beginning of treatment where an awful lot of questions seem to be asked but not a lot of action seems to be happening. The first session will largely be an assessment, and sometimes part of the next few sessions too. This is because a therapist has to have a very good understanding of you, and the challenges you are facing, in order to put together an appropriate treatment plan.

Treatment options

A thorough assessment is also required so that the therapist can judge, with you, as to whether you are at risk of self-harm, and if so, what is required to manage that risk.

Sometimes an assessment will include the use of a questionnaire. This can be a useful part of an assessment, as they make sure that all relevant bits of information are obtained from you. An assessment tool can also help alert the therapist to areas of greatest concern, and later you can compare your current score to past scores to help monitor your progress.

In a way, an assessment is actually part of therapy, because it helps you to better understand yourself, and then therapy is off to a flying start. A good assessment will help you to fit the pieces of your life together and to see a way forward.

The continuum of help

Intensivetreatment

Brief treatment

Self help / Peer / Family support

While this section is focusing on professional help, we should remember that effective treatments range in the time they take and the amount of professional help required. For some people, the use of self-help resources will be sufficient to meet their needs, along with the support of friends and family members, especially if peers and family have become informed about the problems you are facing and the best way to face them.

Even when receiving professional help, a brief treatment can sometimes be sufficient, especially when backed up with self-help resources. By ‘brief’, it is generally meant 10-20 minutes of contact with a health professional with maybe one or two follow-up sessions. But for some people, several sessions (typically in the range of 4-12 sessions of 50-90 minutes duration) will be required to deliver a full treatment. Further episodes of treatment might also be required to consolidate gains, including the occasional follow-up (check-up) session.

Treatment deliveryNot all treatment has to be delivered one-on-one (just you and the therapist). Sometimes couple therapy will help a lot (either to focus on your relationship or so that your partner can be fully informed about your therapy). Occasionally, family therapy will benefit all members of a family, but should be delivered by therapists specially trained in family work.

You will find that group therapy is often available for issues such as depression, general anxiety, stress, anger management, sleep problems, and alcohol and other drug use. These groups can be instead of, or in addition to, individual therapy. Most people feel very nervous about going to a group and having to share some of their thoughts and feelings with others. But when a group works well, you may find yourself soon enjoying being with others who have the same challenges and battles, and both giving and receiving support from your peers.

Many who attend groups say that it was great to realise that they were not alone with their problems, that they were not unique or ‘weird’ in any way. When some members of a group make rapid progress, it tends to spur on other members (‘if they can do it, so can I’), and one of the most powerful ways we learn is by modelling on the achievements of others.

Some people fear getting treatment because they associate treatment with hospital settings and inpatient (stay-in) programs. Such programs exist, and are sometimes necessary for people who require highly specialised care or have become very unwell and need a break and closely monitored care. However, the vast majority of treatment can be successfully delivered from community settings (agencies or private practice) with the client remaining at home. This has the great advantage of the client being able to practise coping strategies in daily life between therapy sessions.

Increasingly, self-help materials are available on the internet. Whether you prefer to use these resources on the Internet or in a booklet form is entirely a matter of choice. On the Internet there is the potential for the material to be more interactive (e.g., you get feedback depending on the information you have entered, etc.), but many people will continue to prefer pen and paper versions.

Effective treatmentsIn general, the research evidence to date indicates that a range of strategies known as cognitive-behavioural therapy (CBT) is effective with mild challenges, lifestyle issues and mental health conditions.

Cognition can be defined as anything to do with our thinking processes – our perception and interpretation of events, our beliefs, values and attitudes, our reasoning and judgment. When we are not travelling too well, it is easy to fall into a pattern of negative thinking which is associated with low mood. We may also have interpretations of situations and events that are not helpful to our current functioning.

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Treatment options

Cognitive therapy will examine your thoughts, beliefs and interpretations about past experiences. Strategies for promoting helpful, realistic thinking are taught and practised. You will learn to challenge your habitual negative thoughts and your faulty beliefs about past events. CBT will make you aware of the link between your thoughts, feelings and behaviour.

The ‘behavioural’ part of CBT refers to:

• reducing our anxiety by learning to tolerate and master our responses to anxiety-provoking triggers in our environment

• learning calming techniques, such as controlled breathing and relaxation

• learning to reduce or eliminate behaviours that are causing us problems

• making sure that we are getting sufficiently rewarding, pleasurable times in our lives by scheduling constructive and enjoyable activities into our daily routine

• learning to solve problems in a structured way and to apply coping strategies

• making changes to our environment and lifestyle to improve our quality of life.

Most people who have plenty of support from family and friends will find that a few sessions of CBT will lead to considerable change in their lives. The skills that are learnt in CBT can then be applied in the future to a wide range of challenges and problems, although some refresher sessions may be required. Self-help programs are usually based on CBT principles.

Some treatments that go by other names (e.g., Motivational Interviewing or Motivational Enhancement, Action Commitment Therapy [ACT], Cognitive Processing Therapy [CPT]) may bring a special emphasis to therapy, but contain the essential elements of CBT.

Treating depressionThe range of strategies known as cognitive-behavioural therapy (CBT – covered above under ‘Effective treatments’) is the preferred approach to treating depression. Excessively negative and unhelpful thoughts about yourself, your future, or the loss of a loved one or something highly valued, are firstly identified. Then you are taught to challenge your negative thoughts (they are usually based on false beliefs, or at the least are inaccurate) and to replace them with helpful and realistic (but not pie-in-the-sky overly positive) thoughts. It may require practice to be able to regularly identify and replace your negative thoughts, as they may have become automatic and highly habitual. This approach will often result in a more balanced and helpful interpretation of events, perception of yourself, and your future.

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A depressed person will benefit from setting goals, taking a structured approach to solving problems, and scheduling activities to obtain more pleasurable and rewarding experiences. Taking part in rewarding activities is critical to our sense of wellbeing.

The benefits will include:

• feeling a greater sense of control over life

• distraction from problems and negative thoughts

• feeling less tired

• improved motivation – the more you do the more you feel like doing

• clearer and more helpful thinking

• getting positive reinforcement through enjoyment, a sense of satisfaction and positive feedback from others.

Treating anxietyGeneralised anxietyGeneralised anxiety is excessive and frequent anxiety and worry about a number of events or activities that a person finds hard to control. Again, CBT is considered the most effective treatment, with the key components being:

• challenging negative and catastrophic thoughts and beliefs

• problem-solving techniques and strategies to address feared problems and their consequences

• arousal/anxiety management, especially relaxation therapy, controlled breathing and other calming exercises which can be applied in a variety of situations.

Panic disorder and agoraphobiaA panic attack is a limited period of intense fear or discomfort, with very heightened arousal of the nervous system. A racing heart and short and shallow breathing (which can lead to dizziness) may occur. Panic disorder is when repeated panic attacks occur and the person is fearful of more attacks. This can lead to the person avoiding places that they fear will induce a panic attack and in some cases having trouble leaving their house (agoraphobia).

CBT is also the most effective treatment for panic disorder and agoraphobia. You will see some overlap with the treatment of generalised anxiety, but the treatment is more targeted on the actual symptoms and situations in which the panic occurs.

Treatment involves:

• becoming aware of the internal body (physiological) sensations/symptoms associated with panic, inducing the symptoms through hyperventilation, and then learning to control the symptoms (this takes away fear of the symptoms, which has been largely responsible for maintaining the panic disorder);

• arousal management through breathing retraining

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Treatment options

• understanding panic disorder and challenging any catastrophic thoughts and beliefs about the events and situations triggering the panic and the panic attacks themselves

• gradual exposure to the feared situations, beginning with the less anxiety-provoking cues and then moving on to more difficult and stronger cues/triggers (systematic and graded exposure); steps up the hierarchy of anxiety-provoking cues/situations occur when the person has reduced their arousal and is feeling comfortable.

While this treatment may seem quite challenging and confronting, it is done in stages and most people will manage it well with very good results.

Social anxietyPeople with strong social anxiety (social phobia) fear and avoid any social or performance situations in which they may experience embarrassment or feel they could be judged or criticised. This can interfere greatly with one’s lifestyle, job and relationships.

The treatment for social anxiety uses the same components of CBT used with other anxiety conditions, with the emphasis on:

• challenging unhelpful thoughts and beliefs

• gradual exposure to the social events that are feared, at which time the following are employed:

– helpful thoughts

– relaxation and arousal management

– social/performance skills.

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Treating PTSDTrauma-focused ‘exposure therapy’ for PTSDGreater detail is provided in this booklet on the treatment for PTSD than for other disorders because the treatment for PTSD is highly specialised and, unfortunately, often under-utilised.

Exposure therapy sits within the CBT approach and has a lot in common with treatment for anxiety conditions in general. Anxiety is mastered by learning to tolerate exposure to the triggers and situations that give rise to fear and anxiety. In PTSD, these triggers can be external to us – certain people, places, activities – as well as internal memories of the traumatic event. In vivo (real life) exposure is used to tackle the external triggers, while imaginal exposure is used to confront the troubling memories of trauma. In both cases, we learn through exposure that unpleasant arousal will subside after a few minutes and that the events prompting the anxiety will not harm us. You can expect the experienced therapist to outline the nature of trauma treatment in accordance with the information found below, which will reassure you that you are receiving specialised, best-practice treatment.

One special variation of trauma treatment is called Eye-Movement Desensitization & Reprocessing (usually referred to as EMDR). In EMDR the person is asked to focus on trauma-related images, thoughts and body sensations while simultaneously tracking the therapist’s finger moving across their field of vision. The results from EMDR treatment are similar to exposure therapy, where the person is encouraged to confront situations that are feared and avoided in their daily life, in addition to the EMDR procedure.

Treatment for recurring trauma-related nightmares might also occur in conjunction with other trauma-focused therapies or alone. This treatment involves ‘re-scripting’ the dream through writing a new account of the dream that removes its distressing content.

What will happen during treatment?

The most important thing when getting help for PTSD is to face, and deal with, the memory of the traumatic event rather than push it into the back of your mind. Your health practitioner will help you to find a safe way to face traumatic memories and confront situations, people or places that you have avoided since the event.

Treatment options

You will be encouraged to gradually recall and think about traumatic memories until they no longer create high levels of distress. You will be encouraged to do so at your own pace and be given skills to manage any distress that emerges during sessions. You will also be helped to go into situations that you want to avoid because they remind you of the trauma or trigger anxiety. Your health practitioner will take things slowly, help you gain control of your fears step by step, and make sure that you never feel overwhelmed by your feelings.

Secondly, you will be encouraged to examine your thoughts, feelings, and interpretations of the event. You will be encouraged to explore thoughts that may make the memories of the event more painful. Many people blame themselves or start seeing the world as a dangerous place after a traumatic event, and need help to grapple with these thoughts.

You can expect to have around 8–12 treatment sessions. However, treatment may last somewhat longer if your distress is severe; you have been exposed to a number of traumatic events; or have lost someone you cared about during the event. It is important to note that a delay in beginning treatment should not affect its success, and that it’s never too late to start addressing the problem.

What if the event I experienced is so distressing that I can’t bear to think about it?

People sometimes fear that they will ‘lose their mind’ if they think and talk about the traumatic event they have been through. While this fear is understandable, thinking and talking about a traumatic experience will not make you lose your mind. It is important to bear in mind that you will be confronting the traumatic experience at your own pace. Your health practitioner will teach you skills so that you won’t feel overwhelmed when recalling traumatic events. While you do this work, he or she will continually check how you are going.

Some people, especially those with a history of chronic PTSD along with other conditions (such as depression), will do best with a comprehensive approach that includes rehabilitative support programs and family support in addition to exposure therapy.

The treatments that you receive will remain your personal choice, even when strongly recommended to you.

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Cognitive Processing Therapy for PTSDCognitive Processing Therapy (CPT) helps clients develop helpful and realistic views regarding the traumatic event(s) they have experienced, replacing unhelpful beliefs about the event that could be playing a role in avoiding painful memories and maintaining their PTSD symptoms. In particular, any guilt-related beliefs and sense of shame are challenged (if a person believes incorrectly that they were responsible in some way for the traumatic event, or its aftermath, it is very difficult to recover). Issues such as trust, safety, anger and control are also addressed.

Part of CPT is writing down accounts of the traumatic event and then reading it back to the therapist. The thoughts and emotions that are contained in the report are discussed and challenged when faulty beliefs are revealed.

Relapse prevention and on-going support for PTSDIn some people, even following treatment, PTSD can be a chronic disorder that relapses from time to time. Preventing a recurrence of symptoms is most important for veterans or other ex-service personnel with PTSD. Times of stress (e.g., family or work problems, bereavements, and financial difficulties) may lead to a recurrence of symptoms in some people. When this happens, it is important to remember that it was expected, and not to feel that you are back to ‘square one’. As long as it is not too severe, and does not last too long, you can deal with it.

As part of treatment, it is important to spend some time planning how to maintain the gains that have been made and how to avoid relapse. Learning to identify the early warning signs of a relapse is important – the earlier you recognise that things are going wrong, the more chance you have of doing something about it. Skills that you’ve learned during treatment can then be applied to cope with any symptoms that return. At times, additional help may be required. Do not hesitate to seek professional assistance if you think you need it. Make sure that you have a plan for where to get help in case of relapse before you finish treatment, so that you know where to seek help quickly if you require it.

Treatment options

More detail on treatment for PTSD can be found in the booklet, Information for People with Acute Stress Disorder (ASD) and PTSD, their Families and Carers. This booklet can also be found at www.acpmh.unimelb.edu.au/resources/resources-community.html

Treating addictive behavioursCBT is also the frontline treatment for addictive behaviours such as excessive alcohol or other drug use and gambling. However, a lot of emphasis is also placed on increasing the person’s motivation for change (because most addictions have a pleasurable component, the decision to cut down or give up is not always easy). Without going into a lot of detail here (you can seek more advice from your GP, the VVCS, State Alcohol and Drug Information Services, QUIT-lines or other health professionals), treatment will usually involve:

• motivational interviewing to increase the person’s discomfort with their addictive behaviour and to prepare and ready them for the process of change

• problem-solving skills

• social skills (including being able to refuse offers)

• self-monitoring of behaviour and setting goals

• strategies to limit the opportunity to engage in the behaviour

• changing thoughts and expectations in relation to the addictive behaviour

• learning coping strategies to resist the urge/craving to engage in the behaviour when in situations associated with the behaviour (e.g., social functions, inside venues, when friends call, when upset, after finishing work)

• establishing alternative behaviours to replace the addictive behaviours

• learning control strategies when aiming to reduce a behaviour, e.g., limiting time drinking or gambling, alternating alcoholic beverages with water etc., drinking low-alcohol beverages, switching to less preferred drinks or forms of gambling

• having a relapse prevention plan in place, e.g., identifying high-risk situations, having a ‘hot-line’ number to call a friend or family member for support when feeling tempted

• treatment for any other conditions, as addictive behaviours are often a way of trying to cope with anxiety, anger or mood disorder.

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The role of medicationsCognitive-behavioural therapy (CBT) for depression and anxiety, and trauma-focused therapy for PTSD, are generally the first choice treatments for these conditions. There will be times, however, when you may be offered medication. Medication may also be used if therapy is not available where you live, or if you would rather not engage in psychological treatments.

The types of medication offered to treat depression, PTSD and other anxiety disorders are usually antidepressants. Even in the absence of depression, antidepressants can help make feelings associated with trauma more manageable. There are different kinds of antidepressants, but research has shown that selective serotonin reuptake inhibitors (SSRIs) are more likely to help. Other forms of antidepressants such as tricyclics or new generation antidepressants can be used as a second option if your symptoms are not getting better with the SSRIs. Remember that antidepressants take a few weeks to reach their full effect, so do not expect immediate results.

If you are having trouble sleeping, medication used in moderation can also be useful. Sleep often improves when other PTSD symptoms are managed through psychological treatment. Sleeping tablets should only be used once other means of improving your sleep have been explored, or on advice from your doctor. They should generally only be taken short-term as some may be addictive. Some antidepressant medication can also help you sleep, particularly if your sleep has been disturbed for over a month.

Benzodiazepines are sometimes used to help manage acute anxiety. However, these drugs have high potential for dependent use, which can then lead to increased anxiety. Benzodiazepines should only be used in the short term and the recommended practice is that anti-depressants are better at helping to manage anxiety in the longer term.

Medications can play a support role to CBT treatment for smoking and alcohol-dependency, especially nicotine replacement therapy when giving up smoking. Some alcohol dependent people are helped by medications that reduce the craving for alcohol. Your doctor or psychiatrist can tell you more about these medications.

Before you start taking medication, you should be given information about possible side effects. When taking antidepressants for the first time, particularly SSRIs, some people can feel agitated, are unable to stay still, and may even have thoughts about suicide. If this happens to you, you should immediately contact the person who prescribed them for you. Likewise, it is important to know what you might experience if you stop taking medication suddenly, forget to take a pill or reduce the amount you are taking. Your health practitioner will be monitoring your response to the medication regularly, particularly in the early stages. It is recommended that you see your health practitioner at least once a fortnight, or weekly if you are severely depressed and feel suicidal.

Treatment options

How long should I take medication for and what should I do if I don’t improve?If antidepressants are working, it is recommended that you take them for at least 12 months. After this period of time, you can stop by gradually reducing the dose, generally over a four-week period. This should only be done after discussion with your doctor and should be carefully monitored. Remember, sleeping tablets should generally only be taken over a short period of time and should be monitored by you and your doctor.

Not all medication works in the same way for everybody. If a particular type of medication is not working for you, your doctor may ask you to try another type, increase the dose, or ask you to try psychological treatment again.

You have an important role to play in whether medications will be helpful and when the time has come to try going without medication (where appropriate). In particular:

• obtain education about the use, effects (including side effects) of the medication

• avoid drug interactions (e.g., alcohol should not be mixed with most medications)

• keep track of your medication use

• discuss any desire to change medication with your doctor or psychiatrist.

What can I ask my health practitioner about medication?How does this medication work?

What can I expect to feel like if it works?

Does it have any side effects and how long will they last for?

How long will it take before I start to feel better?

How long will I have to take it?

What do I do if I forget to take my tablets?

When it’s time, how do I go about stopping the medication?

What will happen when I stop taking it?

Alternative treatmentsThere are a host of other treatment techniques ranging from homeopathy to hypnosis that, while not being ‘run of the mill’, can help some people. It may be that these alternative techniques are used when more mainstream methods have proved ineffective or as an adjunct to those treatments when appropriate. Everyone is different in his or her reaction to therapy and, occasionally, some treatments may do more harm than good, especially in the hands of inexperienced practitioners.

Therefore, we suggest that, before embarking upon these treatments, you should discuss the possibilities with a skilled mental health professional who is knowledgeable in all available resources for treatment.

Coping and protective strategies

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The transition from military life to civilian life can be filled with many challenges, not just in the first few weeks or months, but also over subsequent years. If these challenges are not addressed they can lead to problems that may impact on mental health and wellbeing. This section describes some simple strategies and healthy habits that, along with the support of family and friends, can go a long way to help you meet these challenges and better manage your life.

The following is a list of strategies that may be useful. Many of them are basic commonsense, but that does not mean they are unimportant. On the contrary, if you can do the basics you will go a long way to successfully coping.

Do not try to do everything at once. When you have read the following sections, you may wish to stop for a while and work out a ‘plan of action’. Consider these questions:

• Which strategies sound particularly useful for you?

• Which ones are you prepared to try?

We suggest that you select only one or two to begin with. Work out a plan to achieve them, one at a time, and set yourself some realistic goals for the next week. At the end of the week, review your progress; modify your goals if necessary and/or try some additional strategies for the following week. Over time, you will gradually develop a range of coping strategies and changes to your lifestyle that will help you to feel more in control of your symptoms and get more out of life.

DietEat healthy meals. This sounds so simple, but how many of us actually do it? A poor diet will increase your stress levels. If in doubt about what you should be eating, talk to your general practitioner or a dietician.

Being activeIf you’re undergoing major changes in your life and not travelling too well, it is easy to slip into a pattern of living that falls short on fun, stimulation and positive challenges.

Think about activities that you enjoyed or found meaningful in the past and consider reactivating them, or search out new activities.

Possible activities might include some of the following:

• going for a nature walk

• drawing/painting

• playing a sport

• jogging

• swimming

• joining a club or organisation

• listening to music or playing an instrument

• constructing or repairing something

• outings with family or friends

• watching a movie

• walking a dog

• volunteering

• writing in a journal

• gardening

• going to a restaurant

• computer time (games, Internet)

• fishing

• reading.

Exercise is also vital in effectively managing stress. Exercise helps to burn up those chemicals (like adrenalin) that are hyping you up and will help you to become more relaxed. Half an hour of vigorous exercise most days will greatly improve your fitness and sense of wellbeing.

It might help to draw up a schedule and place it in a prominent place (e.g., on your fridge). Tick off activities as you complete them. Soon you will find you are establishing a routine and you will become more and more motivated to be active.

Sleeping betterA lot of sleep difficulties come down to bad habits. The first step is to recognise these habits, and then you can choose the specific strategies that will help you to change them. Here are some common bad sleep habits and good habits to replace them.

Bad sleep habits

Too active or too much stimulation before going to bed

Irregular sleep routines

Napping during the day

Other activities in bed (e.g., watching TV)

Lying awake for hours and worrying

Consuming caffeine late in the evening

Drinking in the evening

Smoking a lot

Regular use of sleeping pills

Good sleep habits

Spend 30 minutes doing something non-stressful before going to bed and avoid exercise for 3 hours before sleep

Try to go to bed at the same time most nights (it will become a signal for your body that it is time for sleep) and get up at the same time most mornings

Avoid naps

Use your bed only for sleep, sexual activity, and reading material that is not too stimulating

If you do not fall asleep in about 20 minutes, get up and go to another room until sleepy, then try again

Avoid coffee, tea, cocoa, cola drinks, after about 4pm

Don’t have any alcohol for several hours before going to bed (alcohol might help you get off to sleep but causes early waking 2-3 hours later and a disrupted sleep pattern)

Smoking (nicotine) will make you more alert. You may also have breathing-related sleep disturbances caused by long-term smoking (such as sleep apnoea). Avoid smoking as much as possible and consider giving up

Avoid regular use as they are dependency forming and end up disturbing your sleep further

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If you are not sure about your sleep habits, keep a sleep diary for a week or two. Just before going to bed, record the activities of the day and evening, and anything you have consumed in the hours before going to bed. This might help you identify your bad sleep habits and what you need to change.

Do you get anxious about lack of sleep? Are you telling yourself things like: ‘If I don’t get enough hours sleep I won’t be able to function well the next day’, or ‘Poor sleep is having a serious effect on my physical health’ This kind of thinking will make it harder to get off, or back, to sleep.

Instead, tell yourself realistic things like: ‘One night’s poor sleep will not make much difference’ or ‘If I am busy I will hardly notice the difference’.

Remember, do not lie awake in bed worrying, get up and sit quietly or do a low-stimulation activity until you feel sleepy, then return to bed.

Are you worrying about other things at night? Your bed is not a good place to think and worry because it interferes with sleep. Do a deal with yourself. Tell yourself that you will give yourself some ‘worry time’ the following day. There is enough time to worry about things during the day!

It might help to keep a notepad by your bed and jot down any specific worries you are having in bed so it is there for you to consider the following day (then you don’t have to keep the issues in your head).

When you go to bed and worries come into your head, say gently to yourself (and over again if need be): ‘Stop. I have already thought about that today and I’ll review the situation again tomorrow. Now, I’m going to sleep.’

Setting goals and solving problemsSetting goals on a regular basis helps to bring structure, achievement and a sense of satisfaction to our lives. Set small, realistic goals to help tackle obstacles. At first, things may seem insurmountable, but broken down into small steps they are manageable. Some people like to keep lists of tasks to accomplish, crossing them off as they are completed. This can be very rewarding, helping you to acknowledge that you are achieving something.

Establish daily routines (e.g., go to bed at a set time, get out of bed at a set time, plan activities for the day). Routine is very important in helping us to feel in control and to function effectively.

Redefine your priorities and work out what is, and is not, achievable. Try to be realistic – expect neither too much nor too little of yourself. Then focus your energy and resources on those priorities.

If problems are getting in the way of achieving your goals, then take a structured approach to solving problems. It’s easier to solve a pile of problems when you break them down into manageable chunks, decide which problem to tackle first, and decide which actions to take to solve a problem.

Try the following steps

Step 1 Define the problem – the more a problem is clarified in precise terms, the easier it is to solve.

Step 2 Brainstorm possible strategies – list any ideas you can think of, including creative solutions. Brainstorming is often easier and more productive if two or more heads are put together.

Step 3 Choose the best strategies – which ones seem to you to be the most realistic and potentially effective?

Step 4 Set goals – action plans need to be based on goals.

Step 5 Review progress – it is important to take a few minutes at a later date to consider whether you have met your goals.

Helpful thinkingWhen you’re not travelling too well, it’s easy to slip into a pattern of negative and unhelpful thinking that can make you feel worse and make it hard to cope. The good news is that you can learn to identify these negative thoughts, to challenge and interrupt them, and then replace them with thoughts that will help you to:

• be motivated and energised

• cope with challenges

• relate better to others.

Helpful thinking is not the same thing as positive thinking. It’s hard to be positive all the time, especially if you are coping with significant losses, change or stress.

Helpful thinking is realistic thinking. An example of helpful thinking is, ‘This is a tough time for me, but I am doing some things well’.

Take some time to identify your unhelpful thoughts. It is important to challenge the faulty beliefs underlying your unhelpful thinking. There are some common faulty beliefs or thought processes that underlie negative thinking. Ask yourself:

• What’s the evidence that this negative thought is true? Is there another way of looking at this situation? How would someone else see this?

• Am I jumping to conclusions?

• Am I basing my judgment on how I’m feeling rather than what is actually happening?

• Am I showing ‘black and white’ or ‘all-or-nothing’ thinking?

• Am I exaggerating what I think has gone wrong or might go wrong?

• Am I over-generalising? (e.g., because something has gone wrong in the past, I’m expecting things to go wrong now).

• Am I personalising things that go wrong by blaming (putting-down) myself?

• How important is it? Will it affect my entire future?

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It will probably help you to write down the negative or unhelpful thoughts you have identified and their replacement helpful thoughts.

My unhelpful thoughts are

e.g., The kids never help out.

Replacement helpful thoughts

The kids help when encouraged and rewarded.

To help stop a constant stream of worrying and anger-producing thoughts, set aside a specific time each day for thinking about your concerns (e.g., 30 minutes each day between 6:00 and 6:30pm). If unwanted thoughts come into your mind at other times, remind yourself that you will deal with those negative thoughts or worries later in the day.

You could also use this time to practise your helpful thinking statements or thoughts.

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Building support During your service the military may have provided most (or all) of your friendships and social connections. Many of those bonds can become very strong. Once you leave it can be hard to replace those friendships and you may feel a big gap in your life. It is important to rebuild this part of your life, even if you hold onto a few mates from your service days.

Also, when you are not travelling too well it is easy to drift away from, avoid or fall out with, people who could be supportive and helpful. Being isolated for too long is not good for you.

Decide your priority connections (people or organisations) for the next two weeks. Enter details of those you want to connect with, and where or when you will connect with them.


I will try to connect with

Where will I meet them?

When will I meet them?

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Keeping calm – controlled breathingAre you sometimes experiencing any of the following reactions: rapid heartbeat, rapid breathing and feeling tense or nervous? When we get anxious or distressed, our breathing tends to get faster and shallower. This is a natural reaction as our body prepares for ‘fight or flight’. But in most cases, we don’t actually need to either fight or run away. The physical changes that go with an increase in our rate of breathing (such as muscle tension, butterflies in the stomach, feeling light-headed) just make us feel more uncomfortable and anxious.

Getting our breathing back to normal helps to calm our strong emotional and physical reactions and prevents them from getting worse.

Here are the steps of controlled breathing for you to practice:

1. Get comfortable, and either close your eyes or keep them open, whichever feels best for you.

2. Hold your breath and count to 4.

3. When you get to 4, breathe out and say the word relax to yourself in a calming manner.

4. Then breathe using the 6-second cycle ‘In…2…3…, out…2...3…, in…2…3…, out…2...3…, in…2…3…, out…2...3…’

5. Now say the word “relax” to yourself at the end of each exhalation ‘In…2…3…, out…2...‘Relax’, …in…2…3…, out…2...’Relax’, …in…2…3…, out…2…‘Relax’.’ Now try that.

6. At the end of a minute, hold your breath for 10 seconds (or however long is comfortable for you) and then continue breathing using the 6-second cycles. So try that now.

7. Continue breathing in this way until you feel relaxed and calm and then return to your normal breathing.

Practise this exercise every day for up to 5 minutes, depending on how much time you have. Practising the skill on a regular basis when not distressed (such as first thing in the morning) will help you to learn the skill more quickly. You will then be able to use it better at times when it is really needed. Sometimes, you will notice that symptoms of anxiety return after a short while. That’s OK; just do your controlled breathing again for as long as it takes to settle.

Some other tips for keeping calm are:

• use relaxation and distraction to manage stressful reactions

• use social supports; take someone aside to talk, or call someone

• help others to understand any irritable or unusual behaviour that may have resulted from a stressful situation – let them know that, given some time, you’ll be OK.

Reviewing your progressWhenever you set yourself a goal, it is a good idea to also set a date at which you will review your progress. Put this date on a calendar or in your diary. If you are not happy with your progress, you can try again with some new strategies (or fine-tune the old ones), or consider getting professional support (see the ‘Helpful supports’ section at the end of this booklet).


Helpful supports

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Helpful supports

This section lists some of the resources available to veterans and other ex-service personnel (and their families). To find out what is available in your local area, you may wish to talk to your general practitioner, your community health centre, or the VVCS – Veterans and Veterans Families Counselling Service.

Your GP can make a referral to a psychologist with a rebate available through Medicare. Veterans who have a Gold Card and some veterans who have a White Card can get psychology and other mental health care services paid for directly by DVA. Your GP can make a referral to a clinical psychologist, psychologist, mental health social worker or a mental health occupational therapist. These providers can assist with assessment, psycho-education, cognitive-behavioural therapy, relaxation strategies, skills training, interpersonal therapy and counselling. Some tips for how to talk to your GP are provided on the last page.

The following organisations provide specialist assistance and advice:

VVCS – The Veterans and Veterans Families Counselling ServiceVVCS provides counselling and group programs to Australian veterans, peacekeepers and their families. It is a specialised, free and confidential Australia-wide service.

VVCS staff members are qualified psychologists or social workers with experience in working with veterans, peacekeepers and their families. They can provide a wide range of treatments and programs for war and service-related mental health conditions including posttraumatic stress disorder (PTSD).

Services offered include: crisis counselling (face-to-face or telephone, and an emergency after hours toll-free telephone service); individual, couple and family counselling; group programs; education and information resources (including a library); case management roles; and referrals to other treatment services. For veterans and their families who live in rural and remote Australia, there are outreach counsellors or video counselling options.

Call 1800 011 046 (24 hours) VVCS – Veterans and Veterans Families Counselling Service. This number connects with VVCS in your area during business hours, and connects with Veterans Line crisis support after hours. The VVCS webpage has more information on services and programs: www.dva.gov.au/health_and_wellbeing/

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The Department of Veterans’ Affairs (DVA) funds a range of group treatment programs for veterans with PTSD and other mental health conditions through hospital providers. Information about these programs is available at www.acpmh.unimelb.edu.au/trauma/ptsd_programs.html.

Support groupsThere are various support groups, run by veterans themselves or by associations related to the wellbeing of veterans. Some of these are nationwide while others are based only within certain states. As the list of organisations available can be different in various states, we suggest that interested veterans (or their partners and families) contact either the VVCS or your local DVA office for organisations available in your area.

Some links are provided here to DVA websites that you might find helpful:

At Ease

At Ease is a website designed to help you or someone you know recognise signs of mental health problems and to act to improve and maintain health and wellbeing – www.at-ease.dva.gov.au.

The Right Mix

The Right Mix is a website designed to help you find the right balance with your drinking. Have a play with the standard drink tool. The consumption calculator might be an eye-opener! All state and territory alcohol and other drug services and gambling services are listed on this site – www.therightmix.gov.au.

Alcohol and other drug and gambling help services

There is a lot of information and help readily available for alcohol and other drug use. Help services for alcohol and other drugs can be found at your GP, your local health or community centre, or state or territory drug information services. A site dedicated to cannabis use, with self-help information, can be found at www.ncpic.org.au

Depression and anxiety

In addition to help through your GP, VVCS or local health and community centres, there are a number of websites specifically offering help for depression and anxiety. You might like to ‘shop around’ until you find one that you think will be helpful.

Suicide prevention: Operation Life workshops

Workshops are free and open to people who are concerned about family, friends, mates or others in the veteran community. Priority will be given to veterans and their families. Welfare, pension officers and other helpers from ex-service organisations and the veteran community are encouraged to attend. More information is available at VVCS, or from www.dva.gov.au/health_and_wellbeing/

Family support

There are telephone ‘hotlines’ with counsellors trained in the needs of raising children in highly stressed families. You may like to check out the Raising Children Network on the Australian Parenting Website http://raisingchildren.net.au/ for contact details of where to get help.

Helpful supports

How to talk to your GP

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You and your doctor should work in partnership to manage your health and medical conditions, so it is important that you have a regular doctor and that both of you can communicate well. When it comes to staying healthy or living with a medical condition your doctor is one of the most valuable resources you have.

Your doctor can discuss your health risk factors, taking into account your family history and lifestyle.

Some tips for successful visits to your doctor:

Make an appointment to make sure you can see the doctor at a time that suits you.

If your doctor commonly runs late and you usually have to wait, ring to check before hand if he/she is running on time. If the appointment time will be different and it does not suit you, reschedule your appointment. Ring if you are running late, as alternative arrangements may be possible.

If you have a number of issues to discuss, ask the receptionist to book a long appointment.

If you have an urgent problem, let the receptionist know. Most surgeries keep a number of ‘emergency appointments’ free, even though routine appointments may be booked out in advance in busy practices.

Take all your medications with you, or at least a list of your medications, to the consultation, include alternative medications and non-prescription pills such as aspirin and cold tablets.

Consider booking yourself in for a check-up each year, even if you do not feel unwell.

To get the most from your consultation take an active role in your own wellbeing by being an informed patient.

Give your doctor an accurate portrayal of your habits. Lifestyle factors such as diet, physical activity level, sexual activity and drinking or smoking habits can all affect your disease risk. They can also influence how particular medications affect you. Be honest, both about your current lifestyle and about how prepared you are to make any changes to it.

Make a list of the symptoms that you are experiencing. Be as specific as possible, noting the duration, frequency, timing, severity and whether there seems to be any associated triggers or patterns. You can help to explain why a problem is a big concern to you by being specific about your symptoms and how they affect your life.

Discuss any worries or concerns, including money worries, prognosis, confidentiality issues, relationship difficulties and emotional aspects.

Say what is worrying you most first, instead of leaving it till the end of the consultation. Broach the subject early so your doctor can understand how important your concern is to you and give the discussion the time it needs.

If you do not get through everything, you can always make another appointment.

Bring a friend or relative, for moral support, to back up your story, and/or to provide support in case you are not clear on what the doctor says to you.

If you are not sure what your doctor is saying, do not be afraid to ask them to explain it again or write it down for you.

You should leave your doctor’s appointment with a clear understanding of any condition you may have, your treatment and any follow up appointments, tests or other care you may require.

“ Don’t be afraid to speak up no matter how personal or private your problem may feel. Even if your problem is a sensitive one, chances are your doctor has heard it before. ”

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How to talk to your GP

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